Rev Paul Pediatr.

2016;34(4):489---494

REVISTA PAULISTA
DE PEDIATRIA
www.rpped.com.br

ORIGINAL ARTICLE

Factors associated with caries: a survey of students

from southern Brazil
Tássia Silvana Borges, Natalí Lippert Schwanke, Cézane Priscila Reuter,
Léo Kraether Neto, Miria Suzana Burgos ∗

Universidade de Santa Cruz do Sul (UNISC), Santa Cruz do Sul, RS, Brazil

Received 24 September 2015; accepted 21 February 2016

Available online 28 March 2016

KEYWORDS Abstract
Dental caries; Objective: To describe the factors associated with dental caries among students from Santa
Epidemiology; Cruz do Sul, Rio Grande do Sul, Brazil.
Students Methods: A cross-sectional study was conducted in a random sample of 623 students of both
genders, aged 10---17 years old. Tooth decay was performed using the index of the World Health
Organization (1997), DMFT (permanent dentition) that expresses the sum of decayed, missing
and filled teeth per person. The maternal educational level was rated using criteria of the
Brazilian Association of Market Research Companies. The remaining variables were obtained by
a structured questionnaire. Poisson regression analysis was used to test the association between
variables using robust models and a subsequently adjusted model. Data were expressed as
prevalence ratio (PR).
Results: Multivariate analysis identified the following factors related to the experience of den-
tal caries: residence in rural municipalities (PR: 1.15; 95%CI: 1.0---1.3), attending a city school
(PR: 3.30; 95%CI: 1.1---9.4) or a state school (PR: 3.40; 95%CI: 1.1---9.6); and having an illiterate
mother or a mother that only attended up to the 4th year of school (PR: 1.67; 95%CI: 1.1---2.4)
or high school (PR: 1.54; 95%CI: 1.1---2.2).
Conclusions: The presence of caries in students in southern Brazil was associated with residence
in rural areas, mother with little education and attendance to a public school.
© 2016 Sociedade de Pediatria de São Paulo. Published by Elsevier Editora Ltda. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

PALAVRAS-CHAVE Fatores associados à cárie: pesquisa de estudantes do sul do Brasil

Cáries dentárias;
Resumo
Epidemiologia;
Objetivo: Descrever os fatores associados à cárie dentária em escolares de Santa Cruz do Sul,
Estudantes
Rio Grande do Sul, Brasil.

∗ Corresponding author.
E-mail: mburgos@unisc.br (M.S. Burgos).

http://dx.doi.org/10.1016/j.rppede.2016.02.013
2359-3482/© 2016 Sociedade de Pediatria de São Paulo. Published by Elsevier Editora Ltda. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
490 Borges TS et al.

Métodos: Um estudo transversal foi realizado em uma amostra aleatória de 623 estudantes de
ambos os sexos, com idade entre 10 a 17 anos. A cárie dentária foi avaliada utilizando-se o
índice da Organização Mundial da Saúde (1997), CPO-D (dentição permanente) que constitui a
soma de dentes cariados, perdidos e obturados por pessoa. A escolaridade materna foi avali-
ada utilizando-se os critérios da Associação Brasileira de Empresas de Pesquisa de Mercado. As
demais variáveis foram obtidas através de um questionário estruturado. A análise de regressão
de Poisson foi utilizada para testar a associação entre as variáveis, utilizando-se modelos robus-
tos e um modelo ajustado posteriormente. Os dados foram expressos como razão de prevalência
(RP).
Resultados: A análise multivariada identificou os seguintes fatores relacionados à experiência
de cárie dentária: residência em municípios rurais (RP: 1,15; IC95%: 1,0-1,3), frequentar uma
escola municipal (RP: 3,30; IC95%: 1,1-9,4) ou estadual (RP: 3,40; IC 95%: 1,1-9,6); e ter uma
mãe analfabeta ou uma mãe que só concluiu até a 4a série do Ensino Fundamental (RP: 1,67;
IC95%: 1,1-2,4) ou o ensino médio (RP: 1,54; IC95%: 1,1-2,2).
Conclusões: A presença de cárie em alunos no sul do Brasil foi associada com residência em
áreas rurais, mãe com baixo nível educacional e frequentar escola pública.
© 2016 Sociedade de Pediatria de São Paulo. Publicado por Elsevier Editora Ltda. Este é um
artigo Open Access sob uma licença CC BY (http://creativecommons.org/licenses/by/4.0/).

Introduction area, 13,184 inhabitants. The Human Development Index

According to the World Health Organization (WHO), the
prevalence of dental caries among schoolchildren is 90%
in some countries.1 In Brazil, the prevalence in children is
53.4% and in adolescents, 56.5%.2 Dental caries is one of the
most researched oral diseases3,4 and results from a chronic
process that occurs after a certain amount of exposure to
a cariogenic diet and to tooth-susceptible microorganisms.
Caries is considered a multifactorial condition that is trans-
mitted locally and is one of the most prevalent pathologies
in childhood.5,6
Risk factors for dental caries include salivary flow and
composition, cariogenic bacteria present, inadequate fluo-
ride exposure, immune components and genetic factors.7---9
However, other factors, such as lifestyle, behavior, hygiene,
eating habits, social status and sociodemographic factors,
also contribute to the evolution of caries.6,10---12 Oral diseases
affect daily activities; among these activities, increased
absenteeism13 and decreased performance at school and
work have widespread economic and psychological impacts
and can lead to significant reductions in individual quality of
life.14,15 In this context, this study aimed to describe factors
associated with caries among students in Santa Cruz do Sul,
Rio Grande do Sul, Brazil.
Method
A cross-sectional study of 623 students of both sexes, aged
10---17 years old, was conducted from April to December
2012. The sample consisted of students from public and pri-
vate schools in the city of Santa Cruz do Sul, Rio Grande do
Sul, Brazil.
Santa Cruz do Sul has a population of 118,374 inhabi-
tants, according to the census of the Brazilian Institute of
Geography and Statistics (IBGE).16 In the urban area of the
municipality there are 105,190 inhabitants, and in the rural
(HDI) is 0.773. The city currently has 99% of households
served by drinking water with adequate fluoridation. The
municipality has 64 establishments of the Unified Health Sys-
tem (SUS), 12 Basic Health Units (UBS) (4 in the rural area
and 8 in the urban area) and, among them, six have Sur-
geon Dentists. Ten teams are dedicated to the Family Health
Strategy (1 in the rural area and 9 in the urban area) and four
of them have oral health team. In 2012, 14,899 registrations
were made in primary education (1751 in private schools, in
6958 city public schools, and 6190 in state public schools).
In high school, there were 4010 registrations (765 in private
schools and 3245 in public schools).17
The reference population for the study consisted of
approximately 20,540 students in primary and high schools
in the public and private school network of the city of Santa
Cruz do Sul, stratified by rural vs. urban areas and, further,
by center and periphery: north, south, east or west. The
city has a total of 69 schools: eight are private schools,
all of them located in the urban area, 30 are city schools
ans 31 municipal schools. In the rural area, there are six
state schools and 16 city schools.17 In order to calculate
the sample size, Epi-Info program (Centers for Disease Con-
trol and Prevention, Atlanta, GA, USA, version 7) was used.
The prevalence of tooth decay used for the calculation was
56%,2 with 80% power and a standard error of 5%. Based on
these parameters, the minimum required sample size was
362 students. When the confounding variables were added
to control the effect by 20% and 20% for losses and refusals,
the required sample was 522 students.
The inclusion criteria were: informed consent form
signed by a parent/guardian; the adolescent was willing
and able to conduct an examination of the oral cavity; the
adolescent was properly enrolled in the school, and the
adolescent was within the age range of 10---17 years. Both
genders were included in the study. The adolescents were
excluded from the study if they were absent from school
at the time of the oral health evaluation or if they did
Factors associated with caries 491

not permit the evaluation or if they did not complete the with the Declaration of Helsinki. All students who partici-
questionnaires properly. Two attempts of assessment of oral pated in the study had informed consent forms on record
health per student were carried out. signed by their parents or guardians.
To evaluate dental caries, an examiner conducted the
calibration initially, and the kappa test revealed a corre- Results
lation of K=0.90. Calibration was performed between the
examiner of the study and a researcher with extensive prior
In total, 623 students with a mean age of 13.5 years were
experience. The assessment of oral health was performed at
evaluated; among these students, 57.9% were female, 50.1%
the university’s research laboratory by a previously trained
lived in the urban area, 65.3% studied in state schools, and
researcher. The assessment followed the protocol of the SB
59.2% had mothers who were illiterate or who had four
Brazil Project.2 During the oral examination, the student
or less years of schooling. The students reported consum-
and the researcher remained seated in chairs in front of
ing sweets and soft drinks 2---6 times per week, and they
a window in order to obtain the maximum natural lighting.
most frequently consumed chips once per week. Regarding
The mean duration of the dental examination was 10min.
students’ oral hygiene habits, 83.1% brushed their teeth
The test was conducted with a WHO ballpoint probe and
1---3 times per day, and flossing frequency was reported
a number 5 dental mirror, all packed in surgical and auto-
as ‘‘sometimes’’ by 52.0% of the students. Dental caries
claved paper. No radiography was performed, emphasizing
showed positive associations with area of residence, type of
that no pre-drying and brushing or prophylaxis of the teeth
school, maternal level of education and frequency of floss-
were performed before the examination. All the codes and
ing. The mean DMFT index was 2.5 (Table 1), which means
criteria were recorded on individual records for each stu-
that each child had an average of 2.5 decayed or lost or
dent. The index used was the DMFT (decayed, missing and
restored teeth in the mouth at the time of evaluation.
filled/restored teeth) index. The DMFT index measures, in
As shown in Table 2, students living in the rural area of the
a specified population, the average number per person of:
municipality were 25% more likely to develop dental caries
decayed permanent teeth in need of a filling or extraction
(DMFT≥1) compared with those living in the urban area. Stu-
(D), missing permanent teeth that have been removed as a
dents attending municipal or State schools had a five-time
result of caries (M), and filled permanent teeth (F). Some-
greater likelihood of developing dental caries compared
times, the separate components of the DMFT index are used
with those from private schools. Students with mothers who
as a measure of service utilization (e.g., the F component
completed no more than the 4th year of schooling were
is an indication of dental treatment of decayed teeth), and
two times more likely to develop dental caries compared
the M component may suggest what type of dental care has
with children of mothers who had more education. Nev-
or has not been received (i.e., a high M component suggests
ertheless, students with mothers who had completed high
that teeth were extracted as a result of untreated decay).
school had an approximately 81% more chance of develop-
The maternal education level was assessed using a
ing tooth decay compared with students whose mothers had
questionnaire adapted with the criteria of the Brazilian Asso-
completed higher education. Regarding oral hygiene habits,
ciation of Market Research Companies (Associação Brasileira
flossing ‘‘sometimes’’ had a 20% protective effect compared
de Empresas de Pesquisa --- ABEP).18 Three categories were
on the likelihood of caries, compared to not flossing at all.
used: illiterate or up to the 4th year of school, high school
Table 3 presents the analysis adjusted for confounding
education, and higher education. Age of the students was
factors. Living in a rural area, having a mother with a lower
defined by the WHO19 criteria as follows: early adolescence
education level and attending a municipal or state public
(10---13 years), middle adolescence (14---16 years) and late
school were independently associated with the presence of
adolescence (17---19 years).
dental caries.
Oral hygiene was assessed with a questionnaire adapted
from Barros and Nahas,20 with questions related to the
frequency of flossing and tooth brushing. We also used a self- Discussion
administered questionnaire on dietary habits proposed by
Barros and Nahas,20 with questions related to the frequency This study demonstrated independent associations between
of consumption of sweet foods, snacks and soft drinks. students’ DMFT ≥indices and sociodemographic variables
Data analysis was performed using Statistical Package for such as: living in rural areas, attending municipal or state
the Social Sciences (SPSS) software version 20.0 for Win- public schools and being the children of mothers with less
dows (IBM Corp. Released 2011, Armonk, NY: IBM Corp, USA). schooling.
The significance level used was 5%. Data were described by Descriptive analyses of the mean DMFT (2.5) index
absolute and relative percentages. Chi-square tested the indicated good oral health among this population when com-
association of dental caries with other variables. Poisson pared to the Brazilian context. Data from the national oral
regression analysis was applied to verify the association health survey conducted in 2010 showed that the DMFT index
between the dependent (DMFT≥1) and independent varia- at 12 years old was 2.06; at 15---19 years old, 4.01.2 For World
bles using robust models; for these models, significance Health Organization, this result is considered of low sever-
levels of p<0.05 or p<0.20 were adopted. The adjusted ity, being within the range of 1.2---2.6,21 which means that
model included the variables that were considered signif- on average, each child has 1.2---2.6 teeth decayed, missing
icant (p<0.05). or extracted in mouth.
The research project was submitted and approved by the Students living in rural areas had a greater likelihood
Ethics Committee in Research of the University of Santa Cruz of developing dental caries compared with students of
do Sul, under the protocol number 3044/11, in accordance urban areas. Studies conducted in Greece,22,23 Australia,24
492 Borges TS et al.

Table 1 Characterization of students (n=623).

Total DMFT≥1 DMFT=0 p-valuea

n (%) n (%) n (%)
Sex 0.204
Female 361 (57.9) 237 (65.7) 124 (34.3)
Male 262 (42.1) 159 (60.7) 103 (39.3)
Housing area <0.001
Urban 312 (50.1) 176 (56.4) 136 (43.6)
Rural 311 (49.9) 220 (70.7) 91 (29.3)
School type <0.001
Particular 22 (3.5) 03 (13.6) 19 (86.4)
State 407 (65.3) 259 (63.6) 148 (36.4)
Municipal 194 (31.1) 134 (69.1) 60 (30.9)
Mother’s educational level <0.001
Completed college 57 (9.1) 19 (33.3) 38 (66.7)
High school 197 (31.6) 119 (60.4) 78 (39.6)
Illiterate or up to the 4th grade 369 (59.2) 258 (69.9) 111 (30.1)
Consumption of sweets 0.678
1---3 times per day 141 (22.6) 95 (67.4) 46 (32.6)
2---6 times per week 237 (38.0) 151 (63.7) 86 (36.3)
1 time per week 213 (34.2) 131 (61.5) 82 (38.5)
Never 32 (5.1) 19 (59.4) 13 (40.6)
Snack consumption 0.092
1---3 times per day 88 (14.1) 59 (67.0) 29 (33.0)
2---3 times per day 210 (33.7) 144 (68.6) 66 (31.4)
1 time per week 270 (43.3) 164 (60.7) 106 (39.3)
Never 55 (8.8) 29 (52.7) 26 (47.3)
Soft drink consumption 0.375
1---3 times per day 142 (22.8) 89 (62.7) 53 (37.3)
2---6 times per week 248 (39.8) 167 (67.3) 81 (32.7)
1 time per week 211 (33.9) 128 (60.7) 83 (39.3)
Never 22 (3.5) 12 (54.5) 10 (45.5)
Frequency of brushing 0.524
1---3 times per day 518 (83.1) 325 (62.7) 193 (37.3)
4---5 times a day 87 (14.0) 60 (69.0) 27 (31.0)
1---3 times per week/no brushing 18 (2.9) 11 (61.1) 07 (38.9)
Flossing 0.002
Yes/daily 154 (24.7) 109 (70.8) 45 (29.2)
Sometimes 324 (52.0) 185 (57.1) 139 (42.9)
Never 145 (23.3) 102 (70.3) 43 (29.7)
DMFT≥1, decayed, missing and filled/restored teeth; DMFT=0: school caries free.
a p-value, Chi-square test.

Pakistan25 and Brazil26,27 showed a higher prevalence of den-
tal caries and treatment needs in schoolchildren from rural
areas. This result could be strongly associated with the poor
health status and the limited health services access of the
inland population, which emphasizes the urgency of focus-
ing attention on these areas to supply their residents with
health information and with teams of professionals who are
trained to meet their needs.26
In terms of the type of school, public school students
were approximately five times more likely to develop dental
caries compared with students from private schools. Sim-
ilarly, a study conducted in Porto Alegre, Brazil,28 showed
that students from the public school system came from
families with lower education levels and that students from
the private school network came from families with higher
incomes. In our study, approximately 59.2% of the students’
mothers were illiterate or had at most completed only the
4th year of school, in contrast with 9.1% of students whose
mothers had completed higher education.
Several studies in the literature have addressed the rela-
tionship between the state of oral health with lower income
and, consequently, with less educated parents. In most
cases, limited access to information and health-related
negative behaviors are associated with these findings and
special attention should be given to this group.12,29---32 In our
study, regarding oral hygiene, most of the schoolchildren
Factors associated with caries 493

Table 2 Associations between the DMFT≥1 index and Table 3 Associations between DMFT≥1 and other varia-
the following specific variables: housing area, school type, bles: area of residence, type of school, mother’s educational
mother’s educational level, dietary habits and oral hygiene level and oral hygiene habits, adjusted for sex and age.
habits (brushing and flossing frequencies).
Variable Adjusted PR p-valuea
Variable Crude PR (95%CI) p-valuea (95%CI)
Housing area Housing area
Urban 1 Urban 1
Rural 1.25 (1.1---1.4) <0.001 Rural 1.15 (1.0---1.3) 0.030
School type School type
Municipal 5.06 (1.7---14.5) 0.003 Municipal 3.30 (1.1---9.4) 0.026
State 4.66 (1.6---13.3) 0.004 State 3.40 (1.1---9.6) 0.022
Particular 1 Particular 1
School education of mother School education of mother
Illiterate or up to the 4th 2.09 (1.4---3.0) <0.001 Illiterate or up to the 4th 1.67 (1.1---2.4) 0.005
grade grade
High school 1.81 (1.2---2.6) 0.002 High school 1.54 (1.0---2.2) 0.023
Completed college 1 Completed college 1
Frequency of brushing Flossing
1---3 times per week/no 0.97 (0.6---1.4) 0.9 Yes/daily 0.97 (0.8---1.1) 0.703
brushing Sometimes 0.80 (0.7---0.9) 0.003
4---5 times per day 1.09 (0.9---1.2) 0.2 Never 1
1---3 times per day 1
PR, prevalence ratio; CI, confidence interval.
Flossing a Poisson regression with robust adjusted models.

Yes/daily 1.00 (0.8---1.1) 0.9

Sometimes 0.81 (0.7---9.3) 0.004
The limitations of this study are inherent to cross-
Never 1
sectional studies, which do not allow establishing a
Consumption of sweets relationship of cause and effect. However, it must be noted
1---3 times per day 1.13 (0.8---1.5) 0.5 that that the sample was representative of the studied
2---6 times per week 1.03 (0.7---1.4) 0.8 municipality, with random selection of all students from
1 time per week 1.07 (0.7---1.4) 0.6 public and private schools, urban areas and rural areas. The
Never 1 results of this study can only be generalized to populations
Snack consumption with characteristics similar to the studied adolescents.
1---3 times per day 1.27 (0.9---1.6) 0.1 In summary, this study demonstrated that students resid-
2---6 times per week 1.15 (0.8---1.5) 0.4 ing in rural areas, students of state and city schools,
1 time per week 1.30 (0.9---1.6) 0.5 and students of mothers with less schooling experienced
Never 1 a DMFT≥1. Moreover, direct action aimed at implemen-
ting educational and preventive programs on the topics of
Soft drink consumption
hygiene and self-care is necessary, particularly for parents
1---3 times per day 1.14 (0.7---1.7) 0.5
and school communities in rural areas.
2---6 times per week 1.11 (0.7---1.6) 0.6
1 time per week 1.23 (0.8---1.8) 0.3
Never 1 Funding
PR, prevalence ratio; CI, confidence interval.
a Poisson regression with robust (crude) models. We are grateful for the financial support of the Coordination
of Improvement of Higher Education and Research (CAPES),
performed daily tooth brushing (1---3 times), but 2.9% through funding by the Program for Support of Graduate Edu-
reported brushing their teeth 1---3 times per week or not cation Private Institutions (PROSUP), and for the grants from
brushing their teeth at all. As for flossing, most of the CNPq-PIBIC, Bic Fapergs and PUIC-UNISC for the graduate
schoolchildren reported using dental floss only sometimes. students who helped in the collection of data.
Poor oral hygiene practices are directly related to oral
health conditions, particularly to the development of dental Conflicts of interest
caries.33
A study conducted in Thailand with 1156 students with 6
The authors declare no conflicts of interest.
years old and 1116 students with 12 years old demonstrated
a positive association between tooth decay development
and poor oral hygiene practices34 Research conducted in Acknowledgments
Clementina and Gabriel Monteiro, in Brazil, showed that the
sooner children began good oral hygiene practices, the lower We are grateful to the graduate and post-graduate students
the prevalence of early dental caries were.35 who helped in the collection of data.
494 Borges TS et al.

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